Madagascar is just about the only country still struggling with the bubonic plague

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It may be 2013, but the African island of Madagascar is facing a public health threat straight out of the Middle Ages: At least 20 people in the country’s northwest died last week from the bubonic plague, and 2012 saw some 256 plague cases and 60 deaths—more than in any other country in the world.

One major problem seems to be the rat-infested prisons like the notorious facility in Antanimora, which holds 3,000 inmates. The International Committee of the Red Cross in October warned that the facility’s overcrowding and poor sanitary conditions present a serious plague threat—not just to prisoners, but to those outside its walls, too, since inmates’ relatives can catch the disease when they visit the facility, and detainees are often released without having been treated.

To stem infections, authorities have been disinfecting the prison and trying to trap rats. But from the looks of this October ICRC video, officials face an uphill struggle. Prisoners are shown jammed together in cramped quarters teeming with insects and rodents.

The dreaded bacterial infection, which is carried by the fleas that live on rodents, was responsible for an astounding 25 million deaths in Europe during the 14th century, with periodic outbreaks through the beginning of the 20th century, and continued scattered incidents in countries including the Democratic Republic of Congo, Kyrgyzstan, India, Indonesia and Algeria. It produces painful swelling of the lymph nodes and kills up to two thirds of those afflicted—though with antibiotics the mortality rate drops below 15%.

In addition to plentiful rats and too many inmates in an unhygienic prison, Madagascar’s public health system is a shambles. “The aim is to make sure there is no let-up in the fight against the plague in prisons,” said Christoph Vogt, head of the ICRC delegation in Madagascar. He’s got his work cut out for him.